Safe Water System Hand Washing Guide for Health Care Workers
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Safe Water System & Hand Washing Guide for Health Care Workers Photo by Amy A. Parker Edition 4 September 2005 Acknowledgments The following individuals provided valuable assistance in the form of original material or critical review: Organized and compiled by: Amy A. Parker, RN, MSN/MPH, CDC Technical advisory by: Centers for Disease Control and Prevention: Patricia Riley, CNM, MPH Robert Quick, MD, MPH Eric Mintz, MD, MPH Pavani Kalluri, MD Daniele Lantagne, PE Stephen Vindigni, MPH CARE Kenya- Homa Bay Field Station: Sam Ombeki, John Migele, Ajode Meshack, Mary Ayalo, Alex Mwaki, Charles Komolleh Homa Bay District Management Team Nyanza Provincial Management Team - 2 - ~Overview of Safe Water System and Hand Washing with Soap~ The Safe Water System (SWS) is a household-based water quality intervention that has been developed in response to the need for inexpensive, alternative means of water treatment and storage in the short to medium term for populations lacking access to safe water. The intervention has three components: 1. Water treatment in the home with a dilute, locally-produced sodium hypochlorite (bleach) solution (i.e. WaterGuard) 2. Safe water storage containers with a narrow mouth and a lid. (i.e. modified clay pots and jerrycans) 3. Behavior change techniques regarding water treatment, storage, and hygiene. Goals of the Safe Water System (SWS): 1. To improve the microbial quality of water in homes by means of a sustainable technology 2. To decrease death and diarrhea from contaminated drinking water 3. To improve hygienic behaviors related to water use. Photo by: Amy A. Parker Why use SWS? The SWS is simple to use, inexpensive, and effective. It gives households a way to make their water safe until they gain access to a piped, treated water system. WaterGuard solution provides a residual effect against recontamination (Whereas boiling is expensive, time consuming, hard on the environment, and does not protect against residual recontamination.) The SWS containers keep dirty hands or cups out of the water because of the narrow mouth and tight-fitting lid. The SWS reduces diarrhea morbidity by about half in children under five years old. Why wash hands with soap? Hand washing is the number one prevention against the spread of person-to-person infection. Hand washing is the cornerstone of infection-control practice. - 3 - What is the Link between the SWS and Hand Washing with Soap? Together, the SWS and proper hand washing with soap dramatically reduce the risk of diarrheal diseases. Reasons Why It Is Important for Nurses and Public Health Technicians to Promote the SWS and Hand Washing with Soap Health benefits to individuals and the community: 1. Treating household drinking water protects the family from diarrhea. 2. Hand washing reduces the spread of germs that cause diarrhea, respiratory illness, and skin infections. Professional obligation to promote cleaner water and better hygiene practices. ~Components of the SWS~ I. The Bottle of WaterGuard What is WaterGuard? WaterGuard is a 1% sodium hypochlorite solution (dilute bleach) which is used to disinfect water and make it safe for drinking. When should you use WaterGuard? Every time you refill your water container, you should treat the water with WaterGuard. Water should be treated YEAR ROUND. You should even treat your water if you have piped water and store it because the water can become contaminated during storage. Photo by: PSI WaterGuard is a household water treatment intervention and should not be used in boreholes or community wells. How much WaterGuard should be added to a 20 litre container (or 25 litre container in Nigeria)? 1 capful is sufficient for clear water 2 capfuls for dirty water For containers larger than 20 litres, the dose of WaterGuard should be increased proportionately (e.g., 2 capfuls should be used to treat clear water in a 40 litre container). In Nigeria, a 50 litre container of clear water would require 2 capfuls. How long does the bottle last before it expires? The product’s shelf life is 12 months if UNOPENED. After the bottle is opened in the home, the solution should be used up within two to three months because the introduction of air causes it to lose its potency. - 4 - When is the water safe to drink after treating it? Treat the water and shake or stir the container. Then wait ½ hour before drinking. Where should the bottle of WaterGuard be stored? Out of sunlight, out of the reach of children, in a cool, dry place. Who sells the product? Hospital canteens/ kiosks Supermarkets Some pharmacies Other shops Photo by Amy A. Parker Some community-based organizations Cost: KSh 20 per bottle. In Nigeria, one bottle costs about 30 Naira. What are other purposes of WaterGuard besides using it for drinking water? Treated water should also be used for hand washing, washing fruits and vegetables, and cleaning kitchen utensils. Is WaterGuard a prevention or a treatment for diarrhea? WaterGuard is a PREVENTION for diarrhea, whereas Oral Rehydration Solution (ORS) is a treatment. What does WaterGuard taste like? WaterGuard has a chlorine or metallic taste to it. It is important to tell your patients that a slight odor of chlorine means that their water is safe to drink. Limitations of WaterGuard Relatively ineffective against some parasites Reduced efficiency and disagreeable taste or odor that may result when WaterGuard is used to treat water with excessive amounts of organic material, for example in turbid water. Safety Issues and Health Impact: WaterGuard is Dilute and Safe If WaterGuard is accidentally ingested in large quantities by children, there are only minor, transient effects on health. There may be a very low risk of cancer from using WaterGuard which only would be a concern after many decades of regular use in turbid water. The risk of poor growth and development (and even death) from diarrhea is quite high for infants and small children, so the benefits of WaterGuard far outweigh any small risks. This position has been taken by WHO and the world’s leading water experts. Chlorinated water is the norm in most developed countries. Chlorine is used widely in city water systems. - 5 - II. The Recommended Containers: Modified Clay Pots and JerryCans EXAMPLES of MODIFIED CLAY POTS Advantages: Ø Spigot, narrow mouth, and lid reduce risk of recontamination Ø The water is kept cool Disadvantages: Ø Break easily Ø Heavy to carry Photos by Amy A. Parker Ø Vary in volume (making dosing instructions difficult) Ø More expensive than traditional clay pot Ø Spigot may leak EXAMPLES of JERRYCANS Advantages: Ø A narrow mouth for filling Ø Appropriate shape and dimensions so that it is not too difficult to carry Ø Standard volume simplifies WaterGuard dosing Disadvantages: Ø Does not keep water cool Ø Photo by: http://www.stowers.co.nz Over time the exposure to sunlight may damage the vessel causing it to crack Ø Narrow mouth makes cleaning more difficult Ø Some are expensive Containers that are NOT RECOMMENDED: Traditional Clay Pots and Buckets (Or other vessels with a wide mouth and no lid) Traditional Clay Pot Bucket Although these cost less and are readily available, these options DO NOT KEEP YOUR WATER SAFE FROM RECONTAMINATION! Photos by: Amy A. Parker - 6 - If you do not have a modified clay pot or a jerrycan, it is recommended that you use a lid on the container you do have, and that you either pour out the water or retrieve the water with a clean ladle or cup (making sure not to touch your hands in the water). ***Although the use of the recommended safe storage containers is encouraged, patients should be taught to use WaterGuard in whatever storage vessel they can afford for now. The chlorine residual left in the water by WaterGuard protects the quality of stored water. Cleaning Instructions for the Container: Clay pots should be cleaned out with a sisal twine EACH TIME water is added, preferably with detergent. Jerry cans should be cleaned at least once a week to remove bio-film build-up as follows: 1. Pour 1-2 litres of water into the container. 2. Add double the usual dose of WaterGuard (e.g., two capfuls instead of one) 3. Add hard grains of rice or gravel 4. Agitate vigorously. (This step is key!) 5. Pour out solution. III. Behavior Change Techniques ***Behavior change is required for the positive impacts of the SWS and hand washing to take effect! Aspects to consider when dealing with behavior change: Ø Cultural issues / acceptability Ø Awareness of a problem Ø Patient preferences Use motivational interviewing techniques to promote the Safe Water System and Hand Washing with Soap. Motivational Interviewing involves the following elements described in the acronym ‘FRAMES’: Feedback Responsibility Advice Menu (of options) Empathy Self Efficacy Photo by: Amy A. Parker - 7 - 1. Providing Feedback involves non-judgmental sharing of local data on diarrhea rates and water quality within the patients’ community. This also includes education on the causes of diarrhea. 2. Responsibility for change within each patient is emphasized. 3. Advice is given (but in a professional, non-threatening manner). The patient is free to decide how the suggestions fit his or her own personal lifestyle and to accept or reject the advice. 4. Menu of options is given for dealing with the problem. 5. Empathic listening style is important to build the trust of the patients. Photo by Amy A. Parker 6. Self Efficacy, or self confidence in achieving change, is supported. It is important to support any thought, desire, or attempt at behavior change by expressing